Pediatric Gastrointestinal Care Flashcards
1
Q
The primary function of the gastrointestinal (GI) tract is:
A
the digestion and absorption of nutrients
2
Q
Meconium
A
A thick greenish black material consisting of epithelial cells, digestive tract secretions, and residue of swallowed amniotic fluid, is normally expelled from the intestine shortly after birth and provides evidence of patency of the GI tract.
3
Q
Newborn swallowing
A
is an automatic reflex action for the first 3 months, and the infant has no voluntary control of swallowing until the striated muscles in the throat establish their cerebral connections. This begins at about 6 weeks of age.
4
Q
At what age is the infant capable of swallowing, holding food in the mouth, or spitting it out at will?
A
6 months.
5
Q
Pediatric stomach
A
Round until age 2, then gradually elongates until age 7 when it assumes the shape and anatomic position of the adult stomach.
6
Q
Infant stomach
A
The stomach capacity of the infant is smaller than older children, but the emptying time is faster.
7
Q
What 3 processes are necessary for the body to convert nutrients into forms it can use?
A
Digestion, absorption, and metabolism.
8
Q
Nutrients are composed of 6 major substances:
A
carbohydrates proteins fats vitamins minerals water
9
Q
Digestions is…
A
the initial preparation of food for use by the body.
10
Q
Mechanical digestion
A
occurs through a series of neuromuscular actions that move and mix food along the GI tract at a rate suitable for digestion and absorption.
11
Q
Chemical digestion
A
involves five types of GI secretions: enzymes, hormones, hydrochloric acid, mucus, and water and electrolytes.
12
Q
The principle site for absorption of nutrients in the GI tract is the
A
small intestine
13
Q
The most common consequences of GI disease in children include:
A
malabsorption
fluid and electrolyte disturbances
malnutrition
poor growth
14
Q
In GI assessment, the most important basic nursing assessments include:
A
measurement of intake and output, height and weight, abdominal examination, and simple stool and urine tests.
15
Q
PICA
A
an eating disorder characterized by the compulsive and excessive ingestion of both food and nonfood substances.
16
Q
PICA is more commonly found in:
A
children, women (especially during pregnancy), individuals who have autism or cognitive impairment, and those with anemia or chronic renal failure.
17
Q
PICA is clearly associated with the deficiencies of
A
iron and zinc
18
Q
PICA for dirt (geophagia)
A
is the principle risk factor for visceral larva migrans ( a common parasite in children and adults)
19
Q
Encopresis
A
overflow of incontinent stool causing soiling; often caused by fecal retention or impaction
20
Q
Hematochezia
A
passage of bright red blood per rectum, usually indicating lower GI tract bleeding
21
Q
Melena
A
passage of dark-colored, tarry stools caused by denatured blood, suggesting upper GI tract bleeding or bleeding from the right colon
22
Q
Foreign body ingestions are most common in:
A
infants and children between the ages of 6 months and 3 years of age, and are the leading cause of accidental death in children less than 6 years of age. The peak incidence is between 1 and 2 years of age.
23
Q
Primary nursing intervention when considering foreign body airway obstructions
A
prevention of foreign body ingestion through family teaching.
24
Q
Constipation
A
- is a symptom, not a disease
- is defined as a decrease in bowel movement frequency or trouble defecating for more than 2 weeks.
25
Obstipation
having extremely long intervals between defecation
26
Systemic disorders associated with constipation include:
```
hypothyroidism
Hypercalcemia
chronic lead poisoning
antacids
diuretics
antiepileptics
antihistamines
opioids
iron supplements
spinal cord lesions
```
27
Idiopathic or functional constipation
no underlying cause can be identified
28
Chronic constipation
environmental or psychosocial factors
29
Most constipation in early childhood is
due to environmental changes or normal development when a child begins to attain control over bodily functions. A child who has experienced discomfort during bowel movements may deliberately try to withhold stool.
30
Stool softeners such as _______ or ________ may be used for hard stools or anal fissures.
Malt extract
| lactulose
31
Hirschsprung disease (congenital aganglionic megacolon) (HD)
a congenital anomaly that results in mechanical obstruction from inadequate motility of part of the intestine.
32
Pathology of HD
absence of ganglion cells in the affected areas of the intestine, resulting in a loss of the rectosphincteric reflex and an abnormal microenvironment of the cells of the affected intestine.
In most cases the aganglionic segment includes the rectum and some portion of the distal colon.
33
Clinical manifestations of HD
- most children are diagnosed in the first few months of life.
- more common in males with Downs Syndrome
- clinical manifestations vary according to the age when symprtoms are recognized and the presence of complications, such as enterocolitis.
- A neonate usually is seen with distended abdomen, feeding intolerance with bilious vomiting, and delay in the passage of meconium.
- In older children a careful history is helpful.
34
Therapeutic management of HD
- Majority of children require surgery rather than medical therapy with frequent enemas.
- Snare biopsy to locate aganglionic bowel
- Surgical management consists primarily of the removal of the aganglionic portion of the bowel to relieve obstruction, restore normal motility, and preserve the function of the external anal sphincter.
- Constipation and fecal incontinence are chronic problems in a significant proportion of patients after surgical correction.
35
What is the most serious complication of HD?
enterocolitis
36
Gastroesophageal reflux (GER)
is defined as the transfer of gastric contents into the esophagus. This phenomenon is physiologic, occurring throughout the day, most frequently after meals and at night.
37
Gastroesophageal reflux disease (GERD)
GERD represents symptoms or tissue damage that result from GER. GER becomes GERD when complications such as failure to thrive, bleeding, or dysphagia develop.
38
What is the gold standard for diagnosing GER?
The 24-hour intraesophageal pH monitoring study.
39
Therapeutic management of GER
- depends on the severity
- no therapy is needed for the infant who is thriving and has no respiratory complications
- avoidance of certain foods that exacerbate acid reflux (caffeine, citrus, tomatoes, alcohol, peppermint, spicy or fried foods)
- rx: cimetidine/Tagamet, ranitidine/Zantac, or famotidine/Pepcid and PPIs: esomeprazole/Nexium, lansoprazole/Prevacid, omeprazole/Prilosec, pantprazole/Protonix, and rabeprazole/Aciphex
40
Nissen fundoplication
- most common surgical procedure for GERD complications such as recurrent aspiration pneumonia, apnea, severe esophagitis, or failure to thrive, and for children who have failed to respond to medical therapy.
- This surgery involves passage of the gastric fundus behind the esophagus to encircle the distal esophagus.
41
Prognosis of GER
- usually improves by 12 to 18 months
- requires only conservative lifestyle changes or medical therapy
- if severe and remains unsuccessfully treated, multiple complications can occur:
- esophageal strictures
- recurrent respiratory distress with aspiration pneumonia
- Failure to thrive caused by GER can often be managed with medical therapy and nutritional support.
42
PPIs and GER
PPIs are most effective when administered 30 minutes before breakfast so that the peak plasma concentrations occur with mealtime. If they are given twice a day, the 2nd best time for administration is 30 minutes before the evening meal.
43
Irritable bowel syndrome (IBS)
- recently identified as a cause of recurrent abdominal pain in school-age children.
- it is classified as a functional GI disorder.
- Cause of IBS is not clear, but it is believed to involve a combination of motor, autonomic, and psychological factors.
44
Acute appendicitis
inflammation of the vermiform appendix (blind sac at the end of the cecum), is the most common cause of emergency abdominal surgery in childhood.
-Average age of children with appendicitis is 10 years, with boys and girls equally affected before puberty.
45
S/S of appendicitis
1. periumbilical pain, followed by nausea, right lower quadrant pain, and later vomiting with fever.
2. McBurney's point
3. rebound tenderness
* *relief of pain is symptomatic of rupture.
46
Complications from appendiceal performation include:
```
major abscess
phlegmon
enterocutaneous fistula
peritonitis
partial bowel obstruction
```
47
Phlegmon
is an acute suppurative inflammation of subcutaneous connective tissue that spreads.
48
Etiology of appendicitis
- The cause is obstruction of the lumen of the appendix, usually by hardened fecal material (fecalith).
- Swollen lymphoid tissue, frequently occurring after a viral infection, can also obstruct the appendix.
- Another rare cause is a parasite such as enterobius vermicularis, or pinworms, which can obstruct the appendiceal lumen.
49
The cardinal feature of appendicitis is
pain
50
Diagnosis
CT is the image technique of choide, although ultrasound may also be helpful in diagnosing appendicitis.
51
Inflammatory bowel disease (IBD)
ulcerative colitis (UC) and Crohn's
52
Pathophysiology of IBD
- inflammation found with UC is limited to the colon and rectum, with the distal colon and rectum the most severely affected.
- Toxic megacolon is the most dangerous form of severe colitis.
- Crohn's involves any part of the GI tract from the mouth to the anus but most often affects the terminal ileum.
- Crohn's has skip lesions
- UC has continuous segments with varying degrees of ulceration
53
Hypertrophic pyloric stenosis (HPS)
occurs when the circumferential muscle of the pyloric sphincter becomes thickened, resulting in elongation and narrowing of the pyloric canal.
- usually develops in the first few weeks of life causing projectile vomiting, dehydration, etabolic alkalosis, and FTT.
- more likely in full-term infants than premies
- greatest risk is 1st born child of affected mother
54
Clinical manifestations of pyloric stenosis
- projectile vomiting
- may start as early as 1 wk of age and as late as 5 months
- gastric peristalsis may be visible on examination
- olive-shaped mass in epigastrium just to the right of the umbilicus
55
Intussusception
- the most common cause of intestinal obstruction in children between the ages of 3 months and 3 years.
- prevalent in males 5 to 9 months old
- more common in males than females
- more common in children with CF.
- most cases are idiopathic
56
Intussusception s/s
- currant-like jelly stool
- sudden onset of crampy abdominal pain, inconsolable crying, and a drawing up of the knees to the chest in an otherwise healthy child.
- between episodes, the child appears normal
- vomiting
- abdominal mass, sausage shaped
- bloody stool
57
Diagnostic evaluation of intussusception
- barium enema
- rectal examination (reveals mucus, blood, and occasionally a low intussusception itself
* *passage of a normal brown stool usually indicates that the intussusception has reduced itself. This is immediately reported to the practitioner ,who may choose to alter the diagnostic and therapeutic care plan.
58
Malrotation and Volvulus
- Malrotation occurs as a result of the abnormal rotation of the intestine around the superior mesenteric artery during embryologic development. It may manifest in utero or may be asymptomatic throughout life.
- The most serious type of intestinal obstruction because, if the intestine undergoes complete volvulus (the intestine twisting around itself), compromise of the blood supply will result in intestinal necrosis, peritonitis, perforation, and death.
- Loops of distended bowel
59
Malrotation S/S
infants may have intermittent bilious vomiting, recurrent abdominal pain, distention, or lower GO bleeding.
60
Diagnosis of malrotation and volvulus
Imperative that malrotation and volvulus be diagnosed promptly and surgical treatment instituted quickly. An upper GI series is the definitive procedure to diagnose this condition.
61
Therapeutic management of malrotation and volvulus
Surgery to remove the affected area.
| Short gut syndrome is a postoperative complication.
62
Short-bowel syndrome
a malabsorptive disorder that occurs as a result of decreased mucosal surface area, usually because of extensive resection of the small intestine.
-most common cause in children is NEC, volvulus, jejunal atresias, and gastrochisis.
63
Hepatitis Viruses:
Hepatitis A: oral fecal route, improper food handling
Hepatitis B: STD, blood infusions, IV drug use,
Hepatitis C: transmitted parenterally via blood and blood products.
Hepatitis D: occurs in children already infected with HBV. Drug abusers, hemophiacs, persons from endemic areas.
Hepatitis E: enterically transmitted. Fecal-oral route or from contaminated water. Uncommon in children. Not a chronic condition and has no carrier state.
Hepatitis G: blood borne but can also be transmitted by organ transplant. At risk: IV drug users, transfusion recipients, HCV infected persons.
64
Hepatitis Defined
an acute or chronic inflammation of the liver that can result from several different causes.
65
The single most effective measure in prevention and control of hepatitis in any setting is:
hand washing!
66
Obstructions are either ________ or ________.
Mechanical or anitomical
67
Developmental differences in the GI tract for infants and children compared to adults
- Absorptive capacity is diminished; significantly diminished in infants
- Liver is immature; jaundice
- Increased gastric emptying; lots of poopy diapers
- immature esophageal sphincter; frequent burping
68
ABGs with diarrhea
metabolic acidosis
69
ABGs with vomiting
metabolic alkalosis
70
Trophic feeding
feed in very small amounts
71
Dietary recall teaching with parents
Write down everything in a food journal
72
Cleft lip & cleft palate
- most common facial anomaly in pediatrics
- lips more common in males
- palates and more severe defects are more prevalent in females
- 5th and 9th week gestation
73
Cleft lip repair
- elbow restraints (dr order)
- no prone lying, supine only
- keep suture line clean, use saline
- Logan bars to take tension off lip
- Analgesia to reduce crying
- feed as tolerated
74
Cleft palate repair
- myringotomy common
- repair before speech develops; nasal intonation
- no straws or catheter suctioning
- extensive orthodontics, malpositioned dentition & maxillary arches
- speech therapy
75
Esophageal Atresia Tracheoesophageal Fistual (TEF)
- often associated with hydramnios
- often associated with other congenital anomalies
- esophagus can end in a blind pouch
- esophagus and trachea can communicate via a fistula
76
TEF S/S
coughing, choking, cyanosis
3 Cs
**cannot pass catheter
** repeated pneumonia is complication of TEF
77
GERD is most commonly attributed to:
immature esophageal sphincter that results in reflux of gastric contents into the esophagus causing esophagitis.
78
Omphalocele & Gastroschesis
- herniation of bowel through the abdomen
- omphalocele is associated with serious cardiac and chromosomal abnormalities which reduce prognosis for survival
- Third spacing, increased intra-abdominal pressures, decreased filling pressures of the heart common.
79
Most common hernias seen
Inguinal: testicular descent
Umbilical: "sausage from umbilicus"
80
Diaphragmatic hernia
- S/S significant RDS, dyspnea, cyanosis, scaphoid abdomen, diminished CO, diminished breath sounds
- Intubate immediately, FOV, ECMO, opioids, paralytics, prevent met. acid., repair.
- intestines migrate into the chest cavity
81
Anorectal malformations
congenital anomaly involving the anus and rectum; with or without a fistula
82
Anal stenosis
narrowing
83
Imperforate anus
cutaneous membrane covers anus
84
anal agenesis
blind pouch and fistula
85
rectal artresia
rare, anus normal yet rectum is not contiguous
86
Necrotising Enterocolitis (NEC)
- acute inflammatory bowel disease in preterm and high risk infants
- Etiology is unknown but 3 factors seem to play a role: feeding (must feed very slow), intestinal ischemia, colonization by pathogenic bacteria
- Diminished blood supply to the bowel wall causes cellular death.
- Gas forming bacteria invade to produce pneumatosis intestinalis that appears SOAP SUDSY on abdominal xray.
87
S/S of NEC and treatment
```
abdominal distention
hematachezia
septic in appearance
NPO
decompress
antibiotics
serial films
resect/ostomies
```
88
Biliary Artresia
- 1st symptom is severe jaundice (almost green color)
- inflammatory process that causes intra and extra hepatic bile duct fibrosis.
- fatal if not treated within 2 years
- Kasai procedure or Roux-en Y (palliative)
- Liver transplant (true treatment)
